Mental health and HIV/AIDS are closely interlinked, mental health problems, including substance use disorders, are associated with increased risk of HIV infection and AIDS and interfere with their treatment, and conversely some mental disorders occur as a direct result of HIV infections (WHO, 2010).
Incidence studies have demonstrated a high sero-prevalence of HIV infection in people with serious mental illness. Prevalence rates in mental illness in both in and outpatients have been reported to be between 5% and 23%, compared with a range of 0.3% to 0.4% in the general population in the United States of America over comparable time periods. Some studies have reported behavioural risk factors among people with severe mental illness, estimating transmission of HIV/AIDS infection among these to be between 30% and 60% of (WHO, 2008). World-wide reports from the World Bank indicate that mental health disorders, and especially depression, are among the most prevalent health problems, resulting in enormous losses in terms of human resources and economic potential. Unfortunately few studies have attempted to systematically assess mental health care needs in South Africa at community level and little information is available regarding the risk factors associated with these problems (Phielix, Prins and Kirschner, 2010).
Even fewer studies have assessed the prevalence of common mental health problems in primary care settings or at traditional healers. An epidemiological study conducted by Bhagwanjee, Parekh, Paruk, Petersen and Subedar (1998) among rural African adults in KwaZulu-Natal revealed an unexpectedly high prevalence of anxiety and depressive disorders amongst adults (Collinson, 2008). Macleod, Masilela and Malomane (1998) indicate that mental health problems are wide spread, constituting a considerable burden to the community. Both authors conclude that Primary Health Care services need to be improved to ensure that these disorders are adequately recognized and treated in this setting. They further suggested the integration of mental health care services into HIV/AIDS services or Primary Health Care services to ensure that people
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who are suffering from both mental health problems and HIV/AIDS can be treated in one area, which could reduce costs and promote good service delivery to people.
The World Health Organisation (2008) stated that HIV/AIDS imposes a significant psychological burden. People with HIV/AIDS often suffer from depression and anxiety as they adjust to the impact of the diagnosis of being infected and face the difficulties of living with a chronic life-threatening illness, for instance shortened life expectancy, complicated therapeutic regimens, stigmatization and loss of social support, family or friends. HIV infection can be associated with high risk of suicide or attempted suicide.
The psychological predictors of suicidal ideation in HIV/AIDS infected individuals include concurrent substance use disorders, past history of depression and presence of hopelessness. Apart from the psychological impact, HIV/AIDS infection has direct effects on the central nervous system and causes neuropsychiatric complications, including HIV encephalopathy, depression, mania, cognitive disorder and frank dementia, often in combination. Infants and children with HIV/AIDS infection are more likely to experience deficits in motor and cognitive development compared with HIV/AIDS negative children (WHO, 2008). Cognitive impairment in HIV/AIDS has been associated with greatly increased mortality and independency of other factors, such as baseline clinical stage, CD4+ cell count, serum haemoglobin concentration antiretroviral treatment, and social and demographic characteristics (Adewuya, Afolabi, Ola, Ogundele, Ajibare and Oladipo, 2007).
Like any other chronic and fatal disease, HIV/AIDS affects every aspect of a person’s life, including their mental health. Many research studies suggest that mental illnesses are common in people living with HIV/AIDS (WHO, 2008; Bing et al., 2001)conducted a study to estimate the prevalence of psychiatric disorders and substance abuse among American adults infected by HIV/AIDS and found that nearly half of their sample (n=2864) reported some form of psychiatric disorder, such as major depression and psychosis, as well as anxiety disorders, such as general anxiety disorder and panic attacks, and 40% reported having used an illicit drug. Similarly, Israelski et al. (2007) estimated the prevalence of psychiatric co-morbidity of three stress related disorders among Northern Californians receiving primary care for HIV/AIDS. Their study revealed
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that in a sample of 118 people, 56% screened positive for at least one psychiatric disorder. Vitiello (2006) found that 29.1% of all patients studied suffered from psychiatric disorders, namely major depression, dysthymia, generalized anxiety disorder, panic disorder and post-traumatic stress disorder (PTSD).
Sub-Saharan Africa is one of the world regions most affected by HIV/AIDS. The region comprises nearly fifty sovereign countries grouped into five sub-regions, namely Eastern Africa, Southern Africa, West Africa, Central Africa and the islands of the eastern coast of the continent (Beaglehole et al., 2008). The World Bank defines the majority of the countries within the region as middle-income countries. The region has a population of approximately 809115.000, 2.7% (22 million) of whom are living with HIV/AIDS (Population Reference Bureau, 2008). According to the UNAIDS report, 67%
of all the people living with HIV/AIDS world-wide live in this region. The same report indicates that for 2007, 17 million people were newly infected with HIV/AIDS and that 75% of all AIDS related deaths world-wide occurred in this region (UNAIDS, 2008).
The HIV/AIDS prevalence for adults in this region varies substantially from sub-region to sub-region and from country to country, ranging from 23-32% in Botswana and Swaziland, 12-28% in South Africa and to between 2% to 5% in many East African countries (UNAIDS, 2008). The HIV/AIDS prevalence in adults has decreased in a number of East African countries and most notably in Rwanda from 5.2% in 2004 to 3%
in 2008 (UNAIDS, 2008). The prevalence of HIV/AIDS varies in Rwanda from7.3% in urban areas to 2.2% in rural areas (UNAIDS, 2008). Although the HIV/AIDS overall prevalence rate is decreasing in parts of the sub-Saharan region, it is the leading cause of death in the region and fourth in the list of the ten leading diseases for global disease burden (Stuckler et al., 2008). Furthermore, HIV/AIDS is increasingly being regarded as a chronic disease which in turn, contributes to the burden of chronic diseases which is increasing in low-middle income countries (Beaglehole et al., 2008).
The World Health Organization’s (WHO) report on HIV/AIDS and mental health outlines a number of studies which have demonstrated a high prevalence of psychiatric disorders in people living or infected by HIV/AIDS (WHO, 2008). A number of studies
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conducted in different countries in Africa have documented a high prevalence of psychiatric disorders among people with HIV/AIDS (Myer et al., 2008; Adewuya et al., 2007; Sebit, Tombe, Siziya, Balus, Nkomo and Maramba, 2003). These rates range from 19% in South Africa, 59% in Nigeria, 71% in Zimbabwe to 81% in Uganda. This variation in rate may be related to either clinical aspects, such as the stage of the HIV/AIDS disease or the methodology used to determine this prevalence. For example, Myer (2008) studied the common mental disorders among people living with HIV/AIDS in South Africa. This study found the overall prevalence of mental illness in HIV/AIDS infected individuals to be high, with 19% of participants having depression, post- traumatic stress disorder, or alcohol abuse or dependence. In Nigeria, Adewuya et al.
(2007) found that 59% of HIV/AIDS positive people who participated in their study had a co-morbid psychiatric disorder, and this rate was significantly higher than in non- infected people. In Zimbabwe, psychiatric disorders were also found to be high among people living with HIV/AIDS. The findings showed that 71.3% of HIV infected individuals had a co-morbid psychiatric disorder, compared to 44.3% of the HIV/AIDS negative control group (Sebit et al., 2003). In Uganda, Petrushkin, Boardman and Ovuga (2005) found that the total prevalence of psychiatric disorders were 82.6% of which depressive and anxiety disorders were the most common ones.
A number of reasons are given for the presence of psychiatric disorders among people living with HIV/AIDS. Freeman et al. (2005) state that premorbid mental history, effects of the HIV virus on the central nervous system, the psychological impact of living with HIV/AIDS, side effects of medication and results of social stigma and discrimination constitute some of the reasons for the high level of mental disorders affecting people living with HIV/AIDS. However, according to Freeman et al. (2007), not everyone living with HIV/AIDS has a mental disorder.
Research suggests there are some socio-demographic factors and HIV medical related factors that increase the risk of depression among people living with HIV/AIDS. Clinical factors, such as number of HIV related symptoms, time since diagnosis of HIV status, illicit drug use and heavy alcohol use were significantly associated with psychiatric disorders among people living with HIV/AIDS (Myer et al., 2008; Bing et al., 2001). On
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the other hand, socio demographic factors, such as unemployment, marital status, living alone and poor social support were found to be significantly associated with the high prevalence of psychiatric disorders among people living with HIV/AIDS (Adewuya et al., 2007; Bing et al., 2001).
It is argued that there can be no health without mental health and that systematically addressing neuropsychiatric disorders in Primary Health Care is one of the ways in which the burden of co-morbid diseases, especially mental disorders and HIV/AIDS, can be reduced over time (Prince, Saxena, Maj , Maselko and Phillips, 2007). Depression has been found to be associated with lower overall health and poorer quality of life among people living with HIV/AIDS than with HIV negative control groups(Williams et al., 2005).
The World Health Organization (2008) recommended that a successful HIV/AIDS intervention programme should include appropriate strategies for the assessment and management of mental disorders as part of the routine service. Sraelski et al. (2007);
Freeman, Nkomo, Kaffar and Kelly (2008); and Freeman et al. (2005) argue that people receiving Primary Health Care for HIV/AIDS should be routinely screened and treated for symptoms of mental disorders as this has been shown to significantly improve the HIV/AIDS disease outcome. These authors suggest that estimating the prevalence of depression among HIV/AIDS affected people is important to developing and/or improving services for the treatment of mental illness at HIV treatment sites and thus, to improving HIV disease outcome and quality of life.
Rwanda has made a number of efforts to improve the medical care of those affected by HIV/AIDS and it is more than likely that these efforts have contributed to the decreasing adult prevalence rate (UNAIDS, 2008). For example, services for the prevention of HIV transmission from mothers to children have expanded and are accessible in more than half of the country’s health facilities. Furthermore, the rate of male partners participating in mother to child transmission prevention services has increased from 9% in 2003 to 74% in 2006 (UNAIDS, 2008). The sites providing ARVs increased from 76 in 2005 to 165 in 2007 and the ARVs coverage rate grew from 71% to 84% (UNAIDS 2008).
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Although psychiatric disorders, particularly depression, appear to be high in people living with HIV/AIDS, they frequently go undetected and therefore untreated in HIV/AIDS services or care settings (Israelski et al., 2007; Petrushkin et al., 2005). For example, Israelski et al. (2007) found that 56% of participants met the symptom criteria of depression, post-traumatic stress disorder and acute disorders and, of these, only 43%
reported current treatment for any mental health condition. Only 24% of participants reported that they were currently receiving psychotherapy services and only 35%
reported current use of psychiatric medications. Similarly, Petrushkin et al. (2005) found that none among a small sample were receiving any treatment for their psychiatric disorders. Untreated depression among HIV infected people has been found to be associated with poor outcome of HIV/AIDS treatment and is likely to cause immunosuppression (Olatunji, Mimiaga, O'Cleirigh and Safren, 2006). Berger- Greenstein, Carlos, Cuevas, Brady, Trezza and Mark (2007) found that some of the psychiatric symptoms of depression, such as difficulty in concentrating, fatigue and suicidal thoughts, interfere with medication adherence among people living with HIV/AIDS.
The prevalence of mental disorders in people living with HIV/AIDS in South Africa ranges from 19% to 43%. For example, Freeman et al. (2007) estimated the prevalence of mental disorders in this population using a large sample (n= 900). This study found that 43.7% of the total sample screened positive to at least one mental disorder. The most common disorders in this study were depression, psychosis, alcohol abuse and post-traumatic stress disorders. Myer (2008) studied three common mental disorders (depression, post-traumatic stress disorder and alcohol abuse) among individuals living with HIV/AIDS and found that 19% of their sample (n= 88) met the criteria for at least one psychiatric disorder. Four of the most commonly occurring psychiatric problems in people living with HIV/AIDS are mood disorders, suicide, anxiety disorders and substance abuse and two of these are reviewed below.
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2.3.1 Suicide among people living with HIV/AIDS
Suicide and suicidal attempts have been found to be high in people infected by HIV/AIDS. Komiti et (2001) conducted a review of existing literature on suicidal behaviour in people living with HIV/AIDS and found an increase in both suicidal ideation, and completed suicide. Roy (2003) researched the prevalence of suicide among people living with HIV/AIDS and examined the risk characteristics of these patients. In a sample of 149 HIV/AIDS infected patients, it was found that 66 patients (44.3%) had attempted suicide. Gender was related to the increase in suicide attempts, with women being at higher risk (p = 0.01) than men. Other characteristics associated with suicide attempts among people living with HIV/AIDS in Roy’s study was the history of depressive disorders (Roy, 2003). In France, suicide attempts have been found high among people living with HIV/AIDS. Preau (2008) conducted a study with 2932 French people living with HIV/AIDS. The findings indicated that 22% had attempted suicide, a figure which is much higher than the prevalence of suicide attempts in the French general adult population of 8%.
The literature suggest that there are at least three periods in the illness cycle during which time people are more at risk for suicide. Meel (2006) argues that the period following the person’s awareness of HIV/AIDS status is one of the most important risk periods for suicide. The author suggests that this may be exacerbated by an unexpected positive result or a result disclosure for which the person was not adequately prepared beforehand.
2.3.2 Anxiety disorders and HIV/AIDS
Findings from a South African study by Martin (2008) revealed that 34 participants (40%) from a sample of 85 patients recently diagnosed with HIV/AIDS screened positive to post-traumatic stress disorder (PTSD) related to HIV/AIDS, of whom 82.4% were clinically distressed. High rates of anxiety disorders were also reported in Nigeria, where Adewuya et al. (2007) found that 12.5% screened positive for PTSD, 9.1% had social anxiety disorder, 8% had generalized anxiety disorder, 6.8% panic disorder, 4.5% had specific phobia and 3.4% had obsessive disorders. Anxiety is a common symptom in
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HIV-infected patients, particularly when the symptoms are severe or persistent. These disorders include panic disorder, generalized anxiety disorder, obsessive-compulsive disorder and PTSD. Among HIV infected patients receiving medical care, 20.3% were found to have an anxiety disorder, with 12.3% meeting the criteria for panic disorder, such as adjustment disorder and 2.8% having generalized anxiety disorder. Patients with other psychiatric disorders, such as adjustment disorders, major depression, psychosis or substance use disorders can also present with significant anxiety. To help patients receive optimal care, clinicians need to be aware of the differences among these disorders. Furthermore, patients with histories of anxiety or mood disorders were found to be susceptible to recurrence of anxiety symptoms during the course of HIV illness (Vitiello et al., 2006).
The American State Department of Health AIDS Institute (2006) recommend that clinicians should consider the diagnosis of an anxiety disorder when a patient presents with common somatic symptoms, such as chest pain, diaphoresis, dizziness, gastrointestinal disturbances and/or headaches, for which no underlying medical etiologic can be established. Anxiety symptoms, such as worry, nervousness, fear and tension are commonly experienced by people with HIV during periods of their illness, and may be a response to a stressful situation. An anxiety disorder occurs when symptoms interfere with a patient’s daily function, for example if the patient is unable to work, leave home, attend to medical care or if it interferes with personal relationships and causes marked subjective distress (Vitiello et al., 2006; Bing et al., 2001).